Menopause

Article updated and reviewed by Christina S. Chu, MD, Assistant Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Pennsylvania on May 11, 2005.

Natural menopause is the end of menstruation and childbearing capability that occurs in most women around the ages of 50 to 52. Known as the "change of life," menopause is the last stage of a gradual biological process in which the ovaries reduce their production of female sex hormones estrogen and progesterone.

Surgical menopause is the end of menstruation and childbearing capability that occurs as a result of the woman's ovaries and/or uterus being removed.

Description

Ovaries begin to decline in hormone production during the mid-30s and typically continue to decline to around the age of 47; this phase is called perimenopause. During this phase, the process accelerates and hormones fluctuate more, causing irregular menstrual cycles and unpredictable episodes of heavy bleeding. By the early to mid-50s, menstruation ends; this phase is called menopause. Two or three years following menopause is the phase called climacteric.

Causes

The age when a woman has her last period is not known to be related to race, body size or age of first menstruation. Menopause may occur several years earlier or later then the median age of 51.

Symptoms

During perimenopause, estrogen production is low and the ovaries stop producing eggs. As estrogen levels decline, certain signs (or symptoms) of menopause occur. The first sign is a change in the woman's menstrual cycle. Periods may skip or occur more often, and the flow may be heavier or lighter than usual.

The most common symptoms are hot flashes or hot flush. The hot flash may begin before a woman has stopped menstruating and may continue for a couple of years after menopause. A hot flash can be defined as a sudden sensation of intense heat in the upper part or all of the body. The face and neck may become flushed with red blotches, appearing on the chest, back and arms. It is usually accompanied by perspiration and may last a few seconds to several minutes. For some women, the feeling of heat is followed by a feeling of chills. The hot flash may be particularly disturbing during sleep.

Vaginal dryness is another common symptom of menopause. With advancing age, the walls of the vagina become thinner, dryer and less elastic. These changes may lead to painful intercourse.

Four or five years after the final menstrual period, there is an increased chance of urinary tract and vaginal infections. The symptoms include having to go to the bathroom often, feeling an urgent need to urinate, not being able to urinate, or having to go often during the night.

There are telltale symptoms, such as changes in menstrual pattern and the onset of hot flashes, which offer diagnostic clues.

Menopause is suspected when there is a long interval without periods in a woman around the age of 50, particularly if a woman has hot flashes or a low estrogen profile. The low estrogen profile can be discovered during a physical examination by means of an atrophic vaginal smear, the absence of vaginal mucus, or an atrophic endometrium (diagnosed by a biopsy).

Treatment

Some of the changes in menopause can be relieved by giving replacement estrogen in place of the hormone that is no longer made by the body. The decision to take estrogen replacement therapy (ERT) or hormone replacement therapy (HRT), which is a combination of estrogen and progesterone, should be an individualized choice. A woman and her doctor should thoroughly discuss the benefits and risks before beginning therapy.

In recent years, recommendations for taking HRT have changed. While HRT has been shown to be excellent for relieving hot flashes and for preventing osteoporosis-related fractures, it may cause small increases in the risk of other problems such as heart attack, stroke, and breast cancer. Recent studies have also shown a slight increase in the risk of developing dementia. Also, though HRT may relieve hot flashes, a recent large study showed only a small benefit in the relief of insomnia without overall improvement in quality of life for women taking HRT compared to those taking a placebo. The evidence for taking ERT (estrogen alone) is less clear. A large clinical trial of estrogen alone will be closing in 2005, with additional recommendations expected to be forthcoming.

Types Of ERT

There are three (3) types of replacement therapy:

1. Estrogen alone via a pill (Premarin, Ogen, Estrace or ethinyl estradiol), a cream (Premarin or Dienestrol), a vaginal pill (Vagifem), or as a transdermal or skin patch (Estraderm or Estracomb).

2. Cyclical therapy: Estrogen taken daily via a pill or via a patch and a separate progesterone pill (such as Provera) for a certain number of days per month.

3. Continuous therapy: Estrogen plus low dose progesterone in one or two pills taken every day.

women who experience severe hot flashes that are not relieved by other measures

women who experience menopause before age 45, naturally or due to hysterectomy

If the woman has chosen to begin replacement therapy, she must also decide how long she will want to continue this therapy. In general, women should be counseled that the only indication for estrogen replacement therapy is the relief of hot flashes, and that the lowest dose necessary to relieve symptoms should be prescribed for the shortest time necessary.

In general, women who still have a uterus should not take estrogen alone, without progesterone, because of the increased risk of endometrial cancer. Women who still have a uterus and choose to take estrogen alone should have an annual endometrial biopsy to monitor for the development of endometrial cancer. Additionally, the woman who has chosen hormone replacement therapy should have an annual pelvic examination, mammogram, and breast exam, and alert her doctor about any unusual vaginal bleeding or spotting.

Alternatives To Hormone Replacement

If the woman is thinking of foregoing replacement therapy she may want to consider the following drug and non-drug methods of alleviating some of the annoyances of menopause.

For painful intercourse due to vaginal dryness: Staying sexually active, using lubricating jelly (such as Astroglide, Replens, Lubrin and K-Y Jelly) and applying a vaginal cream (such as Estrace or Premarin) once or twice a week can help minimize the discomfort. Non-traditional treatment includes the consumption of phytoestrogens, which are found in soy-based foods.

For urinary tract infections: Drinking plenty of liquids and urinating as frequently and completely as possible.

For osteoporosis prevention and treatment: Several prescription drugs are available to prevent and treat osteoporosis, including alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), and calcitonin. Additionally, taking 1500 mg of calcium and 400 IU of vitamin d each day as well as 45 to 60 minutes of weight-bearing exercise four times a week can also help in the prevention of this problem.

For heart disease: To reduce the risk of heart disease doctors recommend eating a low-fat, high fiber diet, exercising regularly, stopping smoking, and maintenance of a normal body weight.

Questions

Could the irregularity in the menstrual pattern and/or the hot flashes be caused by stress or medication?

Will taking calcium help prevent osteoporosis?

If estrogen and other hormone replacement are given, what are the side effects?

Does estrogen replacement therapy increase the risk of breast cancer or uterine cancer?

Will there be mood swings or depression while going through menopause?